B-2019-0560 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-0560
10510 DEODARA DR CUPERTINO,CA 95014-2431(316 30 036) JAIME AMBRIZ
SAN JOSE,CA 95131
OWNER'S NAME: DATE ISSUED:04/02/2019
OWNER'S PHONE:408-449-9115 PHONE NO:(408)449-9115
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class b Lic.#1050770
Contractor JAIME AMBRIZ Date 02/28/2021 X BLDG X ELECT X PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL— _COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
I
I have and will maintain a certificate of consent to self-insure for Worker's BATHROOMS LIKE FOR LIKE-(115 SF);UPGRADE MAIN PANEL-
Compensation,as provided for by Section 3700 of the Labor Code,for the (200 AMP);(N)TANK-LESS WATER HEATER-SAME LOCATION;
performance of the work for which this permit is issued. INSTALL 1 1/4"GALVANIZED GAS PIPE TO GAS RANGE-(75,100
2. I have and will maintain Worker's Compensation Insurance,as provided for by BTU)
Section 3700 of the Labor Code,for the performance of the work for which this REV#1 -MOVE HEADER 15"TO INSTALL GARDEN WINDOW-
permit is issued. ISSUED 4/30/19
APPLICANT CERTIFICATION Sq.Ft Floor Area: Valuation:$46000.00
I certify that I have read this application and state that the above
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize APN Number: Occupancy Type:
representatives of this city to enter upon the above mentioned property for 316 30 036
inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which
may accrue against said City in consequence of the granting of this permit.
Additionally,the applicant understands and will comply with all non-point PERMIT EXPIRES IF WORK IS NOT STARTED
source regulations Section 9.18. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 4/30/19
Issued by: Jasmine Archbold
OWNER-BUILDER DECLARATION Date:04/02/2019
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons: RE-ROOFS:
1. 1,as owner of the property,or my employees with wages as their sole All roofs shall be inspected prior to any roofing material being installed.If a roof is
compensation,will do the work,and the structure is not intended or offered for installed without first obtaining an inspection,I agree to remove all new materials for
sale(Sce.7044,Business&Professions Code) inspection.
z. 1,as owner of the property,am exclusively contracting with licensed
contractors to construct the project(See.7044,Business&Professions Code). Signature of Applicant:
I hereby affirm under penalty of perjury one of the following three declarations: Date:4/30/19
1. I have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
performance of the work for which this permit is issued.
z. 1 have and will maintain Worker's Compensation Insurance,as provided for by HAZARDOUS MATERIALS DISCLOSURE
Section 3700 of the Labor Code,for the perfonnance of the work for which this I have read the hazardous materials requirements under Chapter 6.95 of the
permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will
1 I certify that in the performance of the work for which this permit is issued,I maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
shall not employ any person in any manner so as to become subject to the Health&Safety Code,Section 25532(a)should I store or handle hazardous
Worker's Compensation laws of California. If,after making this certificate of material. Additionally,should I use equipment or devices which emit hazardous
exemption,I become subject to the Worker's Compensation provisions of the air contaminants as defined by the Bay Area Air Quality Management District I
Labor Code,I must forthwith comply with such provisions or this permit shall will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
be deemed revoked. the Health&Safety Code,Sections 25505,25533,and 25534.
APPLICANT CERTIFICATION _
Owner or authorized agent:
I certify that I have read this application and state that the above information is Date:4/30/19
correct.I agree to comply with all city and county ordinances and state laws
relating to building construction, and hereby authorize representatives of this city CONSTUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agencyfor the performance
of works
to enter upon the above mentioned property for inspection purposes. (We)agree for which ich this permit is issued(Sec. 3097, Civ C.)
to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Name
judgments,costs, and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally,the applicant understands
Lender's Address
and will comply with all non-point source regulations per the Cupertino Municipal
Code,Section 9.18. ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date 4/30/19
Licensed
Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-0560
10510 DEODARA DR CUPERTINO,CA 95014-2431(316 30 036) JAIME AMBRIZ
SAN JOSE,CA 95131
OWNER'S NAME: DATE ISSUED:04/02/2019
OWNER'S PHONE: PHONE NO:(408)449-9115
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#1050770
Contractor JAIME AMBRIZ Date 02/28/2021 X BLDG X ELECT X PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
REMODEL KITCHEN -(220 SF)REPLACE KITCHEN WINDOW
I hereby affirm under penalty of perjury one of the following two declarations: WITH BAY WINDOW KEEPING SAME HEADER;REMODEL(2)
1. I have and will maintain a certificate of consent to self-insure for Worker's BATHROOMS LIKE FOR LIKE-(115 SF);UPGRADE MAIN PANEL-
Compensation,as provided for by Section 3700 of the Labor Code,for the (200 AMP);(N)TANK-LESS WATER HEATER-SAME LOCATION;
performance of the work for which this permit is issued. INSTALL 1 1/4"GALVANIZED GAS PIPE TO GAS RANGE-(75,100
I have and will maintain Worker's Compensation Insurance,as provided for by BTU)
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$46000.00
APPLICANT CERTIFICATION
certify that I have read this application and state that the above APN
information is correct. I agree to comply with all city and county ordinances Number: Occupancy Type:
31630 036
and state laws relating to building construction,and hereby authorize 316
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 04/02/2019 Issued by:Jasmine Archbold
Date:04/02/2019
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
z. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:04/02/2019
1 hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. I have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
i. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the work for which this pen-nit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:04/02/2019
certify that I have read this application and state that the above information is CONSTR CTION LENDING AGENCY
correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signature Date 04/02/2019 Professional